At 40 weeks gestation, a client presents to the obstetrical floor with spontaneous rupture of amniotic membranes at home and is in active labor. The client feels the need to bear down and push. What information is most important for the nurse to obtain first?
- A. Estimated amount of fluid.
- B. Any odor noted when membranes ruptured.
- C. Color and consistency of fluid.
- D. Time the membranes ruptured.
Correct Answer: C
Rationale: The color and consistency of the amniotic fluid are crucial to assess as they can provide valuable information about the presence of meconium, which may indicate fetal distress. Meconium-stained amniotic fluid can lead to complications such as meconium aspiration syndrome in the newborn. Therefore, assessing the color and consistency of the amniotic fluid is the priority in this situation to ensure timely interventions if needed. Estimated amount of fluid (Choice A) may be important but not as critical as assessing for meconium. Any odor noted when membranes ruptured (Choice B) is less relevant compared to assessing for meconium. Knowing the time the membranes ruptured (Choice D) is important but does not take precedence over assessing for fetal distress indicated by meconium presence.
You may also like to solve these questions
The healthcare provider is preparing to give an enema to a laboring client. Which client requires the most caution when carrying out this procedure?
- A. A gravida 6, para 5 who is 38 years of age and in early labor.
- B. A 37-week primigravida who presents at 100% effacement, 3 cm cervical dilation, and a -1 station.
- C. A gravida 2, para 1 who is at 1 cm cervical dilation and a 0 station admitted for induction of labor due to postdates.
- D. A 40-week primigravida who is at 6 cm cervical dilation and the presenting part is not engaged.
Correct Answer: D
Rationale: The client at 40 weeks of gestation with a 6 cm cervical dilation and a presenting part that is not engaged requires the most caution during an enema procedure. An unengaged presenting part increases the risk of cord prolapse, which can be a serious complication during the procedure. This situation demands careful attention to prevent potential complications and ensure the safety of the client and fetus.
Choice A is incorrect as being in early labor does not pose the same level of risk as an unengaged presenting part. Choice B describes a client at 37 weeks with signs of early labor but does not indicate the same level of risk as an unengaged presenting part. Choice C involves a client at 1 cm cervical dilation and a 0 station with no mention of an unengaged presenting part, making it a less critical situation compared to an unengaged presentation, as in Choice D.
The healthcare provider receives a newborn within the first minutes after vaginal delivery and intervenes to establish adequate respirations. What priority issue should the healthcare provider address to ensure the newborn's survival?
- A. Heat loss.
- B. Fluid balance.
- C. Bleeding tendencies.
- D. Hypoglycemia.
Correct Answer: A
Rationale: Corrected Rationale: Immediately after birth, newborns are at high risk for heat loss, which can lead to cold stress and associated complications. Maintaining thermal regulation is crucial to prevent hypothermia and ensure the newborn's survival. By addressing heat loss as a priority issue, the healthcare provider can help stabilize the newborn's temperature and support overall well-being. Choices B, C, and D are not the priority issues immediately after birth. While fluid balance, bleeding tendencies, and hypoglycemia are important considerations in newborn care, heat loss is the primary concern right after delivery to prevent complications related to thermal regulation.
At 20 weeks gestation, a client is scheduled for an ultrasound. In preparing the client for the procedure, the nurse should explain that the primary reason for conducting this diagnostic study is to obtain which information?
- A. Sex and size of the fetus.
- B. Chromosomal abnormalities.
- C. Fetal growth and gestational age.
- D. Lecithin-sphingomyelin ratio.
Correct Answer: C
Rationale: The primary reason for an ultrasound at 20 weeks gestation is to assess fetal growth, gestational age, and anatomical development. This evaluation helps ensure the fetus is developing appropriately and can detect any potential issues that may require intervention. Choices A, B, and D are incorrect because at 20 weeks, the primary focus of the ultrasound is not to determine the sex of the fetus, detect chromosomal abnormalities, or assess the lecithin-sphingomyelin ratio. While these factors may be evaluated in pregnancy, they are not the primary reasons for an ultrasound at 20 weeks gestation.
The client is 24 weeks gestation and reports increased thirst and urination. Which diagnostic test result should the nurse report to the healthcare provider?
- A. Hemoglobin A1C.
- B. Postprandial blood glucose test.
- C. Oral glucose tolerance test.
- D. Fasting blood glucose.
Correct Answer: C
Rationale: An abnormal oral glucose tolerance test result is indicative of gestational diabetes. This test is crucial in diagnosing gestational diabetes as it evaluates how well the body processes glucose after a sugary drink. Reporting abnormal results promptly allows for timely intervention and management to ensure the well-being of both the mother and the baby. The other options are not the primary tests used to diagnose gestational diabetes. Hemoglobin A1C is not recommended for diagnosing gestational diabetes as it reflects long-term glucose control. Postprandial blood glucose and fasting blood glucose tests are not as sensitive as the oral glucose tolerance test for diagnosing gestational diabetes.
In planning care for a client at 30-weeks gestation experiencing preterm labor, what maternal prescription is most important in preventing this fetus from developing respiratory syndrome?
- A. Betamethasone (Celestone) 12mg deep IM.
- B. Butorphanol 1mg IV push q2h PRN pain.
- C. Ampicillin 1g IV push q8h.
- D. Terbutaline (Brethine) 0.25mg subcutaneously q15 minutes x3.
Correct Answer: A
Rationale: The administration of Betamethasone (Celestone) is crucial in cases of preterm labor to promote fetal lung maturation and reduce the risk of respiratory distress syndrome in the newborn. Betamethasone helps enhance the production of surfactant in the fetal lungs, improving their functionality and decreasing the likelihood of respiratory complications upon birth. Butorphanol is an analgesic and not indicated for preventing respiratory syndrome in preterm infants. Ampicillin is an antibiotic used for infection prevention and treatment, not for fetal lung maturation. Terbutaline is a tocolytic agent used to inhibit contractions, but it does not have a direct effect on fetal lung maturity.